Designation of Beneficiary

Member Information

Name

Name of Joint Account Holder

Customer Number

Account Number

Address

Address 2

City

State

Zip

Phone Number

Primary Designated Beneficiary*

*Additional beneficiaries may be later on this form. If a joint member wishes to name different beneficiaries, he/ she will need to complete a separate form.

First Name

Middle Name

Last Name

Address

City

State

Zip Code

Phone Number

Relationship

Date of Birth

Secondary Designated Beneficiary*

*Optional: If primary beneficiary predeceases the member(s), the secondary beneficiary accedes to the primary position.

First Name

Middle Name

Last Name

Address

City

State

Zip Code

Phone Number

Relationship

Date of Birth

Pioneer Rural Electric Cooperative is authorized to register ownership of my capital credit account with Pioneer in my name and pay on death in accordance with the policies of the Cooperative to the primary benefi ciary(ies) named herein or to the secondary benefi ciary(ies) should the primary predecease me. This designation remains in eff ect until amended or revoked by me via written instructions to do so.

Member Signature

Date

Member Signature (If Joint Membership)

Date

Additional Primary Designated Beneficiary(ies)

A fee may be assessed for five or more such beneficiaries.

Additional Primary Designated Beneficiaries

First Name

Middle Name

Last Name

Address

City

State

Zip

Phone Number

Relationship

Date of Birth

Payable on Death Designation of Beneficiary Form

Member Information

Primary Designated Beneficiary*

Secondary Designated Beneficiary*

Additional Primary Designated Beneficiary(ies)

Joint Membership with Right of Survivorship Form

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